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Application fora Permit to Build
Fee must accompany this application
oath' 4//7 19.50
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TO THE BOARD OF SELECTMEN
The undersigned hereby applies for a permit to build, according to the following specifications:
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1. Name of Owner V/p CYR//- 6 o Att5 Address 7'/ WA 5 i ,&i to Ai A✓e
2. Name of Architect (if any)
3. Name of Builder Ray SpN/uk 'e Ca ?a./C,
4. Precinct No. if Lot No. S ' L 3 Plan: Name or No. S/{
5. Name of Street 91jCvgs(,'vt/g-lb. /Q✓� A.M. 54-5 3
6. Purpose of Building S W i n7 I c/j f'o a
7. Material Ait/ in.v wi d V y/t/,4
8. Estimated cost of building/9154 O 610 O
9. Dwelling
10. Cottage —
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11. Heat
12. Basement —
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13. Garage — r ! °
14. Store —
15. Shop —
16. No. of stories —
17. Is there to be a Store in the lower storey
18. Size of Lot. No. of feet front No. of feet rear No. of feet deep
19. Size of building. No. of feet front /114. No. of feet side / No. of feet rear
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20. Distance from nearest building: Front /6 ft.; side ft.; side ft.; rear
21. Distance back from line or street 66 , from rear lot line G O side line
Show by diagram the location of propsed building with relation to distances from adjoining lots, on reverse side.
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Name ,,. z ...
. Address P HY,annig,fiass,02602:
fCet,27,54778
Street Name . 1r.0..d..4..l::C....... O.v.S rvct7` ,l vc,
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g 9L.. Left Side Depth of Lot a
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Right Side Depth of Lot:_ -
Street Name
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• r' BBUILDING PERMIT REVIEW . � "• ::
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APPLICANT: - iNcar (2,AAYt 5 BLDG PERMIT.NO
LOCATION OF 'PROPERTY: w•`j/4k- - DATE FILED [7 J—� / •
THE FOLLOWING CHECK OFF SHEET IS DESIGNED TO CLARIFY THE PROCEDURES AN-aNDIVIDUAL
MUST FOLLOW.IN ORDER TO OBTAIN_ A PERMIT TO BUILD OR ALTER A.BUILDING THE BUILDING
•DEPARTMENT"WILL. CHECK ON _THEA FOLLOWING: (A):- CONSERVANCY DISTRICT.S: .(B)':t HISTORICAL
DISTRICTS (C);: FLOOD PLAINS-'ZONING, AND WILL BE RESPONSIBLE FOR ASSISTING THE _
APPLICANT THROUGH-THE FOLLOWING AGENCIES
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i. RESIDENTIAL BUILDING: •• -• - - -
A) ' CHECK WITH THE HEALTH DEPARTMEN`f IN REFERENCE TO SEPTIC SYSTEMS FOR SEWAGE •
DISPDSAC
B) CHECK WITH CONSERVATION sCOMMITTEE IF THE LOT .BORDERS ON ANY TYPE OF WETLANDS
EXAMPLES:• STREAMS, PONDS, .RIVERS, OCEAN-, "BAY, BOGS, MARSH,: ETC: ,--:; - : ..
• C) CHECK WITH PLANNING BOARD 'FOR LOT RELEASE r
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2 COMMERCIAL-BUILDING a • '
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: A) ; ENGINEERING DEPARTMENT FOR PARKING AND DRAINAGE REQUIREMENTS,. TOPOGRYHY SITE
PLAN REVIEW_..i h.. 1 -yR n i :� •
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B) CONSERVATION COMMITTEE IF LOT BORDERS ANY TYPE OF WETLANDS _
C) PLANNING BOARD TO SEE IF LOT COMPLIES WITH ZONING BY—LAWS --
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0) BOARD OF HEALTH-FOR SEWAGE DISPOSAL REQUIREMENTS, HEALTH RELATED ACTIVITIES. •
EXAMPLES: SAUNA . BATHS, SWIMMING POOLS, RESTAURANTS, ETC.
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'E) • FIRE DEPARTMENT—FOR' PROPERTY PROTECTION, PERSONAL SAFETY, (SPRINKLERS, SMOKE ' -
DETECTORS)
REVIEWED BY
1. JNGINEERING DEPART•MENT YES • DOES NOT APPLY SIGNATURE?_, .� : DATE E7
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•2.:vCONSERVATION COMMITTEE:. .YES '.DOES NOT •APPLYSIGNATURE �s'� � � x,em - DATE." `1 so
3. -p[ARNfNG-BOARDYES " DOES •NOT APPLY_SIGNATf E DATE
4 •vBOAR0 OF HEALTH YES •• NOT APPLY✓SIGNATAirR f ,yy DATEi—��
5. FIR�NT: . _ - YES_DOES NOT APPLY_SIGNA E ✓}. ' ' - DATE
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